- Hamad Medical Corporation

Transcription

National Conference in Patient safety
Workshop:
Root Cause Analysis (RCA) and Failure
Mode and Effect Analysis (FMEA)
Dr. Nadir Kheir; PhD
April 2016
QuM-UAS-Jordan-NK- March 2016
1
Disclaimer:
PRESENTING AUTHORS HAVE NO RELATIONSHIPS TO DISCLOSE
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Objectives
By the end of this workshop, the participant shall be able to :
1. Explain what is meant by the terms Route Cause Analysis and Mode
Failure and Effect Analysis
2. Describe the use of each term in health care environments
3. Explain the difference in the utilization between the two terms
4. Apply this knowledge in simulated practice in advance to
application into clinical practice (use the NHS as a model option)
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RCA: What is it?


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Root cause analysis is a systematic process used to
address problems or non-conformance to identify the
source of the problem
A root cause is the underlying breakdown or failure of a
process which, when resolved, prevents the problem from
reoccurring
In health care, a problem often has more than one cause
RCA is a retrospective investigation
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An important aspect of RCA is the use of
a systematic approach to examine
errors, removing the focus on individuals
in the process of analyzing the situation
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Process of RCA

All factors that lead to errors should be examined in
order to meet the ultimate goal of identifying ways or
system defenses to prevent repetition of the error
Form a Team to investigate by
asking:
What happened?
How did it happen?
Why did it happen
What should be done to prevent it from happening again?
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The “5 Whys” technique
• Examine breakdown in the process
by asking five or more whys to drill
down to the “root cause”
• CAUTION: avoid a premature
answer
• Use cause-and-effect diagram
(such as a fishbone diagram) to
visualize the relevant issues:
people, processes, materials,
environment, and management
issues related to the event
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Source:
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Detection Factors
National Patient Safety- Apr 2016
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Contributory Factors
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Contributory Factors Framework
Detailed list of contributory factors collected from incident
investigation in Healthcare Settings
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•
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•
•
•
•
•
•
Patient factors
Individual staff factors
Task factors
Communication factors
Team & social factors
Education & training factors
Equipment & resource factors
Working conditions/environment factors
Organisational & strategic factors
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Fish Bone Diagram
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Change Analysis Tool
CDP: Care Delivery Problem; SPD: Service Delivery Problem
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Barriers Analysis Tool
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'Pareto effect' or '80/20' rule:
80% of undesired behaviour will be related to 20% of
causes
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Failure Mode and Effect Analysis

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A ‘prospective’ process
Proactive; to PREVENT occurrence of failures
A systematic method of identifying and preventing
product and process failures before they occur
Ddoes not require a specific case or adverse event
Rather, a high-risk process is chosen for study, and
an interdisciplinary
A team asks: “What can go wrong with this process and how can we prevent
failures?”
http://www.the-hospitalist.org/
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Case

72-year-old patient admitted to your hospital with findings of an acute
abdomen requiring surgery. The patient is a smoker, with Type 2 diabetes
and an admission blood sugar of 465, but no evidence of DKA. She
normally takes an oral hypoglycemic to control her diabetes and an ACE
inhibitor for high blood pressure but no other medications. She is taken to
the OR emergently, where surgery seems to go well, and post-operatively
is admitted to the ICU. Subsequently, her blood glucose ranges from 260
to 370 and is “controlled” with sliding scale insulin. Unfortunately, within 18
hours of surgery she suffers an MI and develops a postoperative wound
infection 4 days after surgery. She eventually dies from sepsis.
Discuss how RCA and FMEA could be demonstrated in this
scenario
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Case-contd
RCA:
Causal factors: lack of use of a beta-blocker preoperatively and
lack of use of IV insulin to lower her blood sugars to the 80–110
range
FMEA:
An interdisciplinary team asks the question (before any incident
happens): “What can go wrong with this process and how can
we prevent failures?”
The team decides to conduct an FMEA on controlling blood
sugar in the ICU or administering beta-blockers perioperatively
to patients who are appropriate candidates
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Possible Findings of FMEA
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A significant risk encountered in achieving tight glucose control in the range
of 80–110 includes hypoglycemia
Common pitfalls of insulin administration include administration and
calculation errors that can result in 10-fold differences in doses of insulin
If an inadequate amount of solution is flushed through to prime the tubing,
the patient may receive saline rather than insulin for a few hours, resulting in
higher-than-expected glucose levels and titration of insulin to higher doses
The result would then be an unexpectedly low glucose several hours later
Other details of administration, such as type of IV tubing used and how the IV
tubing is primed, can greatly affect the amount of insulin delivered to the
patient and thus the glucose levels
 The advantages of FMEA include its focus on system design rather than on a single
incident such as in RCA
 By focusing on systems and processes, the learning and changes implemented are
likely to impact a larger number of patients
23
Group Work

Each group will be required to think of a specific
problem, and develop a RCA technique to arrive at
the root cause
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- Hamad Medical Corporation

Transcription

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